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Case report
Left atrial wall dissection after on-pump coronary surgery
Disección de la pared auricular izquierza tras cirugía coronaria con circulación extracorpórea
Jose Manuel Villaescusa-Catalana,b,
Corresponding author
jmvillaescusa92@gmail.com

Corresponding author.
, Salvador Romero-Molinac, Walid Al-Houssainia,b, Alexey Lavreshina,b, Carlos Porras-Martína,b
a Department of Cardiac Surgery, Hospital Virgen de la Victoria de Málaga, Malaga, Spain
b Instituto Biosanitario Málaga (IBIMA), University of Malaga (UMA), Spain
c Department of Anesthesiology, Hospital Virgen de la Victoria de Malaga, Spain
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    "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">Atrial dissection is an uncommon entity&#44; defined as a forced separation of layers of the left atrial creating a gap from the mitral or tricuspid annular area to the interatrial septum or left atrial wall&#46;<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">1</span></a> As a rare and severe complication after cardiac surgery&#44; there is a limited knowledge about pathophysiology&#44; clinical presentation and management&#46; A spontaneous etiology has been described&#44; although most cases appears iatrogenically due to cardiac surgery&#46;<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">2</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">Left atrial dissection &#40;LAD&#41; is more frequently associated with mitral valve surgery and it is extremely uncommon in isolated bypass grafting&#46; We present a left atrium dissection developed in a 65-year-old male underwent triple coronary artery bypass grafting &#40;CABG&#41; on-pump and it was successfully managed conservatively&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Case report</span><p id="par0015" class="elsevierStylePara elsevierViewall">A 65-year-old male with medical history of diabetes mellitus noninsulin dependent and arterial hypertension was urgently admitted with suspected unstable angina &#40;Canadian Cardiovascular Society III&#41;&#46; Coronary angiography showed severe lesions in anterior descending artery&#44; circumflex and right coronary artery&#46; With these findings&#44; it was decided to perform triple CABG&#46;</p><p id="par0020" class="elsevierStylePara elsevierViewall">Preoperative transthoracic echocardiogram &#40;TTE&#41; relevant findings presented moderate left ventricular hypertrophy with preserved left ventricular function&#46; Aortic valve had a mild regurgitation&#46; The left atrium was slightly dilated with a posterior&#8211;anterior diameter of 40<span class="elsevierStyleHsp" style=""></span>mm with no mitral regurgitation&#46;</p><p id="par0025" class="elsevierStylePara elsevierViewall">Before entering the operating room&#44; the patient had persistent symptoms of myocardial ischemia despite the optimal medical treatment&#46; Because of refractory symptoms we started with the intra-aortic balloon pump counterpulsation via left femoral artery &#40;Arrow&#44; Maquet Medical&#44; Germany&#41; &#40;IABP&#41; prior to anesthetic induction&#46; Anesthetic procedures were uneventful&#46;</p><p id="par0030" class="elsevierStylePara elsevierViewall">The surgical procedure was performed using the standard cannulation&#46; Blood cardioplegia at a ratio of 4&#58;1 was delivered anterogradely and retrogradely&#46; The retrograde cardioplegia &#40;RCP&#41; catheter &#40;DLP&#174; Silicone Coronary Sinus Perfusion Cannula with Manual-Inflate Cuff&#44; Medtronic Inc&#46;&#44; Minneapolis&#44; MN&#41; equipped with pressure monitor line was placed in the coronary sinus and it was verified intraoperatively by transesophageal echocardiogram &#40;TEE&#41; visualization in four chambers view&#44; 0&#176;&#46; After first session of anterograde cardioplegia&#44; 50<span class="elsevierStyleHsp" style=""></span>cc of retrograde cardioplegia were infused&#46; The monitorization revealed a large RCP pressure increase above 120<span class="elsevierStyleHsp" style=""></span>mmHg and perfusionist immediately stopped the infusion and RCP was removed&#46; A second dose of anterograde cardioplegia was infused after 20<span class="elsevierStyleHsp" style=""></span>min of isquemia time&#46; Triple coronary bypass was performed using bilateral mammary arteries as a Y graft and one saphenous vein&#46; During hemostatic time there was no evidence of bleeding and patient was admitted in Critical Care Unit&#46;</p><p id="par0035" class="elsevierStylePara elsevierViewall">Initially upon entering the unit&#44; noradrenaline was initiated at low dose due to hypotension caused by vasoplegia&#46; The patient was extubated 4<span class="elsevierStyleHsp" style=""></span>h later without incidents&#46; Transthoracic echocardiography was performed in spontaneous ventilation to reevaluate biventricular contractility&#46; Surprisingly&#44; it showed a new large heterogeneous image in the left atrium that occupied a wide part of it without Doppler flow inside&#46;</p><p id="par0040" class="elsevierStylePara elsevierViewall">Urgent TEE showed a large mass &#40;51<span class="elsevierStyleHsp" style=""></span>mm<span class="elsevierStyleHsp" style=""></span>&#215;<span class="elsevierStyleHsp" style=""></span>52<span class="elsevierStyleHsp" style=""></span>mm&#41; occupying almost the entire left atrium&#44; with heterogeneous echodensity and ecolucent images without Doppler flow or SonoVue&#174; &#40;sulphur hexafluoride microbubbles&#41; echocontrast filling &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>&#41;&#46; That image was suggestive of atrial wall dissection with probable entry at the level of the coronary sinus due to its location&#46; Objectivation of cul-de-sac in its ends supported our hypothesis&#46; In this case&#44; although the dissected lumen was large and right ventricle was borderline&#44; it did not develop any blood flow obstruction and no mitral valve changes with no mitral regurgitation&#46; The clinical evolution was satisfactory&#44; withdrawing IABP and pharmacological support during the first 36<span class="elsevierStyleHsp" style=""></span>h of the postoperative course&#46; Right heart catheterization was no performed&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0045" class="elsevierStylePara elsevierViewall">Therefore&#44; we managed LAD conservatively with close observation&#46; Patient received antiplatelet treatment and no-anticoagulation due to his high risk of let wall rupture and his sinus rhythm&#46; During the in-hospital stay&#44; a tomography cardiac scan was requested showing findings compatible with the presence of LAD &#40;<a class="elsevierStyleCrossRef" href="#fig0010">Fig&#46; 2</a>&#41;&#46;</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0050" class="elsevierStylePara elsevierViewall">After 6 days&#44; the patient was discharged with subsequent follow-up by Cardiology Department&#46;</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Discussion</span><p id="par0055" class="elsevierStylePara elsevierViewall">The appearance of LAD in perioperative period of CABG is extremely rare&#46; In our case&#44; clinical and echocardiographic dissociation is especially remarkable&#46; Managing LAD in the immediate postoperative period is not trivial as a result of its possible clinical impact&#46; Surgical intervention was thoroughly discussed interdisciplinary but considering the patient&#39;s hemodynamic stability the risk-benefit analysis favored a conservative management&#46;</p><p id="par0060" class="elsevierStylePara elsevierViewall">LAD is truly unusual even more after CABG surgery as inform some reviews&#46; Some reviews of published cases set up mitral valve surgery as the most frequent etiology recently&#46; Fukuhara analyzed his results from 1991 to 2012&#44; showing a prevalence of 0&#46;02&#37; after coronary artery bypass grafting &#40;CABG&#41; and 0&#46;16&#37; of mitral valve patients&#46;<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">3</span></a> Martinez-Sell&#233;s et al&#46; submitted in their work a prevalence of 0&#46;84&#37; in the postoperative follow-up of mitral valve patients&#46;<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">4</span></a> Analyzing etiologies trend over time there is a light increase in percutaneous procedures related to the development of these new techniques&#46;<a class="elsevierStyleCrossRefs" href="#bib0080"><span class="elsevierStyleSup">5&#44;6</span></a> Moreover&#44; It has been related with a cardiac tumor appearance&#46; Physiopathology would be related with the presence of a pressurized inflow into the entry of the dissection which can be originate from the left ventricle&#44; left ventricular outflow tract and retrograde cardioplegia infusion&#46; Last one would probably have been the origin of our case&#46;</p><p id="par0065" class="elsevierStylePara elsevierViewall">Use of retrograde cardioplegia is a widely established technique&#46; Retrograde myocardial cardioplegia has many advantages such as uniform distribution of cardioplegia despite proximal coronary vessel occlusion or critical stenosis&#44; it colds down and protect right ventricle and helps to avoid the risk of distal embolization&#46;<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">7</span></a> There are many reports of coronary sinus injury or rupture due to an RCP cannula&#44; but few reports of LAD&#46;<a class="elsevierStyleCrossRefs" href="#bib0095"><span class="elsevierStyleSup">8&#44;9</span></a> Risk of these problems may be further reduced&#46; Manual palpation&#44; damp pressure trackings and TEE appearances are helpful in diagnosing this problem&#46; The perfusionist should check infusion pressures and the coronary sinus &#40;CS&#41; waveform during RCP delivery&#46; Changes in the waveform may indicate cannula malposition&#44; loss of balloon seal&#44; or&#44; more rarely&#44; CS rupture&#59; such changes should prompt immediate cessation of RCP delivery&#46;</p><p id="par0070" class="elsevierStylePara elsevierViewall">The dissection triggers a large cavity between the endocardium and epicardium of the left atrium&#46; LAD could result in hemodynamic compromise due to occlusion of the left atrial cavity&#44; pulmonary veins or mitral inflow obstruction emerging hemodynamic instability&#44; low cardiac output and pulmonary edema&#46; In our patient clinical onset was different&#46; He had hemodynamic improvement that allowed the withdrawal of mechanical and pharmacological supports in the first 36<span class="elsevierStyleHsp" style=""></span>h of the postoperative course&#46; Because of his clinical stability and his satisfactory evolution&#44; surgical treatment was ruled out&#46;</p><p id="par0075" class="elsevierStylePara elsevierViewall">LAD Surgical treatment is the most frequently used option&#46; There are different surgical approaches including entry closure<a class="elsevierStyleCrossRef" href="#bib0105"><span class="elsevierStyleSup">10</span></a> and internal drainage connecting false lumen with the right atrium&#46;<a class="elsevierStyleCrossRef" href="#bib0110"><span class="elsevierStyleSup">11</span></a> Despite the absence of clinical guidelines for the management of this pathology&#44; there are some aspects that should lead us to perform an active attitude such as instability hemodynamic due to flow obstruction or acute rupture provocating cardiac tamponade&#46;</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Conclusions</span><p id="par0080" class="elsevierStylePara elsevierViewall">LAD after coronary artery bypass grafting is an extremely rare entity&#46; Perioperative echocardiography is an essential examination for patients undergoing cardiac surgery&#46; A conservative approach with a close follow up in asymptomatic patient could be an appropriate strategy&#46;</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Informed consent</span><p id="par0085" class="elsevierStylePara elsevierViewall">Informed consent was obtained by the patient to publish the results in the article&#46;</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Conflict of interest</span><p id="par0090" class="elsevierStylePara elsevierViewall">None&#46;</p></span></span>"
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        "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Atrial dissection is an uncommon entity after cardiac surgery&#46; There is not an extensive knowledge about pathophysiology&#44; clinical presentation and management&#46;</p><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">We report the case of a 65 year-old male with angina pectoris and diagnosed of three vessels stenosis in angiography&#46; Three coronary artery bypass grafts were performed with on-pump technique&#46; After the operation&#44; the echocardiography showed heterogeneous material in left atrium occupying most of the left atrium&#46; Left atrial wall dissection was diagnosed&#46; Due to hemodynamic stability&#44; we decided a conservative management and a close follow up with images test &#40;echocardiography and computed tomography&#41;&#46; Six months after the operation&#44; the patient remains asymptomatic&#46;</p><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">High values in the pressure line of retrograde cardioplegia could lead to left atrial dissection&#46; Conservative approach may be an option in stability situation&#44; requiring a close follow up&#46;</p></span>"
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        "resumen" => "<span id="abst0010" class="elsevierStyleSection elsevierViewall"><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">La disecci&#243;n de aur&#237;cula izquierda es una entidad infrecuente tras una cirug&#237;a card&#237;aca&#46; No existe un gran conocimiento sobre esta entidad&#44; su presentaci&#243;n cl&#237;nica y manejo&#46;</p><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">Presentamos un caso de un var&#243;n de 65 a&#241;os con angina <span class="elsevierStyleItalic">pectoris</span> y diagn&#243;stico de estenosis de 3 vasos en la angiograf&#237;a&#46; Se realiz&#243; un triple <span class="elsevierStyleItalic">bypass</span> coronario con circulaci&#243;n extracorp&#243;rea&#46; Tras la cirug&#237;a&#44; el ecocardiograma mostarba un material heterog&#233;neo que ocupaba la mayor parte de la aur&#237;cula izquierda&#46; El paciente fue diagnosticado de disecci&#243;n de la pared auricular izquierda&#46; Debido a la estabilidad hemodin&#225;mica&#44; se opt&#243; por el manejo conservador y seguimiento estrecho con pruebas de imagen &#40;ecocardiograf&#237;a y tomograf&#237;a computarizada&#41;&#46; Seis meses despu&#233;s de la operaci&#243;n&#44; el paciente no refiere ning&#250;n s&#237;ntoma cardiovascular&#46;</p><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Valores elevados en la l&#237;nea de presi&#243;n de la cardioplej&#237;a retr&#243;grada pueden ocasionar una disecci&#243;n de la pared de la aur&#237;cula izquierda&#46;</p><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">El manejo conservador puede ser una opci&#243;n en situaci&#243;n de estabilidad&#44; con un seguimiento estrecho&#46;</p></span>"
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Article information
ISSN: 11340096
Original language: English
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2024 June 34 12 46
2024 May 28 21 49
2024 April 34 19 53
2024 March 39 8 47
2024 February 51 13 64
2024 January 43 9 52
2023 December 54 11 65
2023 November 43 17 60
2023 October 65 23 88
2023 September 28 12 40
2023 August 34 19 53
2023 July 30 4 34
2023 June 44 10 54
2023 May 55 1 56
2023 April 33 2 35
2023 March 1 1 2
2023 February 0 10 10
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es en pt

¿Es usted profesional sanitario apto para prescribir o dispensar medicamentos?

Are you a health professional able to prescribe or dispense drugs?

Você é um profissional de saúde habilitado a prescrever ou dispensar medicamentos